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A Journal on Diseases of the Respiratory System
Official Journal of the Italian Society of Thoracic Endoscopy
Indexed/Abstracted in: EMBASE, Scopus, Emerging Sources Citation Index
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Minerva Pneumologica 2003 September;42(3):115-26
Green light for first-line intervention: respiratory failure due to exacerbations of chronic obstructive pulmonary disease successfully treated using non-invasive positive pressure ventilation
Ram F. S. F.
Aim. Non-invasive positive pressure ventilation (NPPV) is being used increasingly in the management of patients admitted to hospital with acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease (COPD). The aim of this study is to determine the efficacy of NPPV in the management of patients with respiratory failure due to acute exacerbations of COPD.
Methods. A systematic review of randomised controlled trials comparing NPPV plus usual medical care (UMC) with UMC alone in trials that recruited patients admitted to hospital with respiratory failure due to an exacerbation of COPD with admission PaCO2>6 kPa.
Results. Fourteen studies were included in the review. NPPV resulted in decreased mortality (relative risk, RR, 0.52; 95% confidence interval, CI, 0.35, 0.76), decreased need for intubation (RR 0.39; 95% CI 0.30, 0.52) and reduced treatment failure (RR 0.48; 95% CI 0.37, 0.63). Within 1 h of NPPV initiation significant improvements were seen in pH (weighted mean difference, WMD 0.03; 95% CI 0.02, 0.04), PaCO2 (WMD 0.40 kPa; 95% CI 0.78, -0.03), and respiratory rate (WMD 3.08 bpm; 95% CI 4.26, 1.89). In addition, complications associated with treatment and length of hospital stay were also reduced with NPPV (RR 0.38; 95% CI 0.24, 0.60 and WMD 3.24 days; 95% CI 4.42, 2.06, respectively). There was also a trend towards improvement in PaO2 and length of intensive care unit (ICU) stay.
Conclusion. Good quality randomised controlled trials provide convincing data for NPPV to be recommended as first line intervention in addition to UMC in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD. A trial of NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, as a means of reducing mortality, avoiding endotracheal intubation and decreasing treatment failure. NPPV can be applied in a general ward or a high dependency area as ICU admission seems unnecessary. This would reduce the costs and the burden on health care resources. However, patients with more severe acidosis would benefit from specialist care provided in ICU.